Muhammad Aditya Alfarizki

71.2017.007

Pembimbing : dr. Rizal Daulay, Sp.OT, MARS

 Motor System of the upper limbs
examination

1. Before Starting
 Introduce yourself to the patient.
 Confirm his name and date of birth.
 Explain the examination and obtain his consent.
 Position him and ask him to expose his arms
completely.
 Ask if he is currently experiencing any pain.
 
 The examination
Inspection :
 Look for abnormal posturing.
 Look for abnormal movements such as tremor,
fasciculation, dystonia, athetosis.
 Assess the muscles of the hands, arms, and shoulder
girdle for size, shape, and symmetry.
 You can also measure the circumference of the arms.
 
 Tone
 Ensure that the patient is not in any pain.
 Ask the patient to relax the muscles in his arms.
 Test the tone in the upper limbs by holding the patient’s
hand and simultaneously pronating
 and supinating and flexing and extending the forearm. If
you suspect increased tone, ask the patient to clench his
teeth and re-test. Is the increased tone best described as
spasticity (clasp- knife) or as rigidity (lead pipe)?
Spasticity suggests a pyramidal lesion, rigidity suggests
an extra-pyramidal lesion.
 
 Power
 Test muscle strength for shoulder abduction, elbow flexion and
extension, wrist flexion and extension, finger flexion, extension,
abduction, and adduction, and thumb abduction and oppo-
sition. Compare muscle strength on both sides, and grade it on
the MRC muscle strength scale:
0 No movement.
1 Feeble contractions.
2 Movement, but not against gravity.
3 Movement against gravity, but not against resistance.
4 Movement against resistance, but not to full strength.
5 Full strength.
 
 Reflexes
 Test biceps, supinator, and triceps reflexes with a
tendon hammer (see Figure 24). Compare both sides.
If an upper limb reflex cannot be elicited, ask the
patient to clench his teeth and re-test.
 
 Cerebellar Signs
 Test for intention tremor, dysynergia, and dysmetria (past-
pointing) by asking the patient to carry out the finger-to-nose
test.
– place your index finger at about 2 feet from the patient’s face.
Ask him to touch the tip of his nose and then the tip of your
finger with the tip of his index finger. Once he is able to do this,
ask him to do it as fast as he can. And remember that he has
two hands!
 Then test for dysdiadochokinesis.
– ask the patient to clap and then show him how to clap by
alternating the palmar and dorsal surfaces of one hand. Once he
is able to do this, ask him to do it as fast as he can. Ask him to
repeat the test with his other hand
 
 After the examination
 Thank the patient.
 Ensure that he is comfortable.
 Ask to carry out a full neurological examination.
 If appropriate, indicate that you would order some
key investigations, e.g. CT, MRI, nerve con-
 duction studies, electromyography, etc.
 Summarise your findings and offer a differential
diagnosis.
 Sensory system of the upper limbs
examination

 Before Starting
 Introduce yourself to the patient.
 Confirm his name and date of birth.
 Explain the examination and obtain his consent.
 Position him so that he is comfortably seated and ask
him to expose his arms and to position
 them so that the palms are facing towards you.
 Ask if he is currently experiencing any pain.
 
 The examination
 To examine the sensory system, test light touch, pain, vibration sense, and
proprioception.
 Do not forget to inspect the arms before you start. In particular, look for muscle
wasting, fasciculation, scars and other obvious signs.
 Light touch (not light rub or stroke). Ask the patient to close his eyes and
to say ‘yes’ each time he is touched with a wisp of cotton wool. Apply the
cotton wool to his sternum as a test. Then apply it to each of the
dermatomes of the arm, moving from the hand and up along the arm.
Remember to compare both sides against each other, asking, “Does it feel
the same on both sides?”.
 Pain. Ask the patient to close his eyes and apply a sharp object – ideally a
neurological pin – to the sternum and then to each of the dermatomes of
the arm, as above. Compare both sides against each other. If there is any
loss of or difference in sensation, map out the area affected
 
 Vibration. Ask the patient to close his eyes and apply a vibrating 128 Hz
tuning fork (not the smaller 512 Hz tuning fork used in hearing tests) to the
sternum and then over the bony promi- nences of the arm, starting with
the interphalangeal joint of the thumb and moving up to the wrist and then
the elbow (only if not felt more distally). Compare both sides against each
other, asking the patient to tell you when he feels the vibration stop (you
can hasten this by touching the tuning fork).
 Proprioception. Ensure that the patient does not suffer from arthritis or
some other painful con- dition of the hand. Ask him to close his eyes. Hold
the distal interphalangeal joint of his index finger between the thumb and
index finger of one hand. With the other hand, move the distal phalanx up
and down at the joint, asking him to identify the direction of each
movement. Hold the joint and phalanx from the sides, i.e. from their lateral
and medial aspects. Tell the patient something like, “I’m going to move your
finger up and down. Is this up or down?” “What about this? And that?” Again,
compare both sides.
 
 After the examination
 Thank the patient.
 Ensure that he is comfortable.
 Ask to carry out a full neurological examination.
 Summarise your findings and offer a differential
diagnosis.
 Motor system of lower limbs
examination

Before Starting
 Introduce yourself to the patient.
 Confirm his name and date of birth.
 Explain the examination and obtain his consent.
 Position him and ask him to expose his legs.
 Ask if he is currently experiencing any pain.
 
 The examination
 Inspection :
 Look for deformities of the foot.
 Look for abnormal posturing.
 Look for fasciculation.
 Assess the muscles of the legs for size, shape, and
symmetry. You can also measure the circum-
 ference of the quadriceps or calves.
 
 Tone
 Ensure that the patient is not in any pain.
 Ask the patient to relax the muscles in his legs.
 Test the tone in the legs by rolling the leg on the
bed, by flexing and extending the knee, and/
 or by abruptly lifting the leg at the knee.
 
 Power
 Test muscle strength for hip flexion, extension, abduction and
adduction, knee flexion and ex- tension, plantar flexion and
dorsiflexion of the foot and big toe, and inversion and
eversion of the forefoot. Compare muscle strength on both
sides, and grade it on the MRC scale for muscle strength:
0 No movement.
1 Feeble contractions.
2 Movement, but not against gravity.
3 Movement against gravity, but not against resistance.
4 Movement against resistance, but not to full strength.
5 Full strength.
 
 Reflexes
 Test the knee jerk and ankle jerk with a tendon
hammer (see Figure 26). Test the knee jerk by
raising and supporting the knee with one arm and
striking the patellar tendon with the other. To test
the ankle jerk, abduct and externally rotate the hip
and flex the knee and ankle. Then strike at the
Achilles’ tendon. Compare both sides. If a lower
limb reflex cannot be elicited, ask the patient to
hook flexed fingers and pull apart while you re-test.
 
 test for clonus by holding up the ankle and rapidly
dorsiflexing the foot (2–3 beats is normal). Test for
the Babinsky sign (extensor plantar reflex) by
scraping the side of the foot with your thumbnail or,
ideally, with an orange stick. The sign is positive if
there is extension of the big toe at the MTP joint, so-
called ‘upgoing plantars’.
 
 Cerebellar signs
 Carry out the heel-to-shin test.
– lie the patient on a couch. Ask him to run the heel
of one leg down the shin of the other,
 and then to bring the heel back up to the knee and to
start again. Ask him to repeat the test with his other
leg
 
 Gait
 If he can, ask the patient to walk to the end of the
room and to turn around and walk back. (See
Station 37: Gait, co-ordination, and cerebellar function
examination.)
 
 After the examination
 Thank the patient.
 Ensure that he is comfortable.
 Ask to carry out a full neurological examination.
 If appropriate, indicate that you would order some
key investigations, e.g. CT, MRI, nerve con-
 duction studies, electromyography, etc.
 Summarise your findings and offer a differential
diagnosis.
 Sensory system of the lower limbs
examination

7. Before startinng
 Introduce yourself to the patient.
 Confirm his name and date of birth.
 Explain the examination and ask for his permission
to carry it out.
 Position him on a couch and ask him to expose his
legs.
 Ask if he is currently experiencing any pain.
 The examination

 o examine the sensory system, test light touch, pain, vibration sense, and proprioception.
 Do not forget to inspect the legs before you start. In particular, look for muscle wasting, fascicu- lation, scars,
and any other obvious signs.
 Light touch (not light rub). Ask the patient to close his eyes and to say ‘yes’ each time he is touched with a
wisp of cotton wool. Apply the cotton wool to his sternum as a test. Then apply it to each of the dermatomes
of the leg, moving from the foot and up along the leg. Remember to compare both sides against each other,
asking, “Does it feel the same on both sides?”.
 Pain. Ask the patient to close his eyes and apply a sharp object – ideally a neurological pin – to the sternum
and then to each of the dermatomes of the leg, as above. Compare both sides against each other. If there is
any loss of or difference in sensation, map out the area affected.
 Vibration. Ask the patient to close his eyes and apply a vibrating 128 Hz tuning fork (not the smaller 512 Hz
tuning fork used in hearing tests) to the sternum and then over the bony promi- nences of the leg, starting
with the interphalangeal joint of the big toe (test more proximally only if not felt distally). Compare both
sides against each other, asking the patient to tell you when he feels the vibration stop (you can hasten this by
touching the tuning fork).
 Proprioception. Ensure that the patient does not suffer from arthritis, gout, or some other pain- ful condition of the
foot. Ask him to close his eyes. Hold the interphalangeal joint of his big toe between the thumb and index finger of
one hand. With the other hand, move the distal phalanx up and down at the joint, asking him to identify the
direction of each movement. Hold the joint and phalanx from the sides i.e. from their lateral and medial aspects. Tell
the patient something like, “I’m going to move your toe up and down. Is this up or down?” “What about this? And that?”
Again, compare both sides. If the patient is able to stand, you can also perform Romberg’s test (see Station 37: Gait,
co-ordination, and cerebellar function examination).
 
 After the examination
 Thank the patient.
 Ensure that he is comfortable.
 Ask to carry out a full neurological examination.
 If appropriate, indicate that you would order some
key investigations, e.g. CT, MRI, nerve con-
 duction studies, electromyography, etc.
 Summarise your findings and offer a differential
diagnosis.